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CASE REPORTS

A rare complication of Port-A-Catheter fracture

Asmaa Adel Milyani1, Samah M. Alharbi2, Nasser Bustanji3, Walid Asaad4, Abdulmoein Eid Al-Agha∗5

1King AbdulAziz University, Faculty of Medicine, Saudi Arabia2King AbdulAziz University Hospital, Department of Paediatrics, Saudi Arabia3King AbdulAziz University Hospital, Department of Paediatric Surgery, Saudi Arabia4King AbdulAziz University Hospital, Department of Interventional Radiology, Saudi Arabia5King Abdulaziz University Hospital, Department of Paediatric Endocrinology, Saudi Arabia

Received: August 10, 2018 Accepted: September 25, 2018 Online Published: October 23, 2018DOI: 10.5430/css.v5n1p1 URL: https://doi.org/10.5430/css.v5n1p1

ABSTRACT

Background: Obtaining a central line access is an essential procedure that is necessary in various settings to facilitate theadministration of medication. An implantable central line, also known as a portacath, is a subtype with a reservoir installed into asubcutaneous pocket and attached to a catheter.Case presentation: This is a case of a fractured portacath implanted for the administration of calcium in a two year old femaleresulting from high syringe pressure.Discussion: Complications range from immediate injury to vascular and surrounding structures to a delayed manifestation ofinfection and device malfunction. Catheter fracture in vivo is a very rare complication especially in the paediatric population.Conclusions: Appropriate size of syringe should be checked with the portacath manufacturer prior to use in order to avoidfracture as a result of high syringe pressure.

Key Words: Port-A, Catheter, Fracture, Central, Line

1. INTRODUCTION

Central line access is a common resort in the critical care set-ting due to its ease in facilitating the repetitive administrationof medications directly into the systemic circulation withoutcompromising the venous integrity of the patient.[1] Addi-tional uses comprise blood pressure monitoring in haemo-dynamically unstable patients, provision of total parenteralnutrition, and long-term provision of a reliable vascular ac-cess for extended durations.[2] The implantable central line,or in other words a portacath, is generally installed by asurgical procedure where a reservoir is implanted in a subcu-taneous pocket with an attached catheter that pierces into oneof the central veins, more frequently the internal jugular and

subclavian veins.[1, 3] In spite of its popular utility in clinicalpractice, it is associated with many complications; these aregenerally approached as either immediate or delayed com-plications. Immediate complications are largely related tothe technique at the time of insertion, manifesting as a re-sult of injury to surrounding organs and vasculature, whiledelayed complications are more inherent to device malfunc-tion and the development of infection. Device dysfunctionranges from surrounding thrombosis and calcification to de-vice fracture,[4] the latter of which predisposing to a varietyof ramifications as a result of subsequent embolisation ofthe detached fragment. These include but are not limitedto endocarditis, cardiac perforation, arrhythmias and sepsis,therefore prompting apt recognition and appropriate inter-

∗Correspondence: Abdulmoein Eid Al-Agha, Prof.; Email: aagha@kau.edu.sa; Address: King Abdulaziz University Hospital, Department ofPaediatric Endocrinology, Jeddah 21589, P.O.Box 80215, Saudi Arabia.

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vention.[5] We report this case of port catheter fracture dueto high syringe pressure in line with the SCARE criteria.[6]

2. CASE REPORT

A two-year-old female with Type 2 Vitamin-D DependentRickets was admitted for intravenous administration of highdose calcium gluconate therapy to correct her underlyingbiochemical, clinical and radiological manifestations of se-vere rickets. An expert paediatric surgeon had placed animplantable portacath in her right internal jugular vein (IJV)uneventfully. A chest x-ray was consequently done to en-sure proper placement of the catheter (see Figure 1). Dailyadministration of calcium gluconate at a dose of 13 g (1.6g/kg/day) diluted in Dextrose 5% solution was thereaftergiven at a rate of 21.6 ml/hour (concentration was within theacceptable limits for calcium infusions) that had continuedwithout any complications. During her third week of therapy,sudden resistance was encountered by one of the nurses uponchanging the needle. Multiple trials to flush the catheter withdifferent needle sizes were attempted to no avail, with nobackflow and sustained resistance. A chest x-ray was per-formed for visualisation and had revealed a discontinuationof the catheter into two freestanding attachments (see Figure2). She was then immediately transferred for the removalof the catheter under fluoroscopic monitoring by the paedi-atric surgeon in conjunction with interventional radiologists(IR). Intraoperatively, a vascular ultrasound outlined throm-bosis and calcification in the right IJV where the catheterwas placed (see Figure 3), the IR tried initially to retrieve itthrough the femoral vein but it was not possible, only for thepaediatric surgeon to remove it and find that catheter was par-tially broken with a small attachment between the two partsthat had not been visible in the x-ray (see Figure 4). Patientwas soon anticoagulated with intravenous heparin. A full andcomplete multidisciplinary investigation had unraveled thatthe catheter breakage was a result of high pressure causedby the use of a 5 cc syringe for flushing the catheter, whichwas recognised by the nursing department. Upon extensivereview of hospital policy and clinical practice guidelines,none were found for the care of an implantable portacath.Pharmacy report had confirmed that the dose of medicationand rate of infusion were appropriately in line with the guide-lines and therefore could not have been responsible for thebreakage. For follow up, a lecture was held to educate allnurses on the recommendation regarding the subsequent useof a 10 cc syringe when flushing implantable port catheters toavoid this adversity in the future. It is noteworthy to mentionthat parental consent was obtained on behalf of the patientfor the publication of this article.

Figure 1. Chest radiograph showing the placement of theport catheter within the IJV

Figure 2. Chest radiograph showing dissociation of the portcatheter

3. DISCUSSIONMechanical complications of port catheters such as fragmentdissociation and embolisation is considered a rare adversitythat has been estimated to occur at an incidence rate between0.4%-1.8%.[7] However, it is a potentially life threateningincident with a reported morbidity of 71% and 38% mortal-ity.[8] It is most frequently witnessed in the subclavian veinin association with pinch-off syndrome, where the catheter

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is entrapped between the clavicle and the first rib, leading toits fracture. The second most common cause occurs duringcatheter removal, when the catheter is lodged within an in-growth of epithelium or fibrin sheath that has formed aroundit.[9] However, in our case, the port catheter was insertedin the right internal jugular vein and the fracture was nota consequence of either pinch-off syndrome or catheter en-trapment. Additional causes have included shearing of thecatheter lumen during needle insertion and rupture of catheteras a result of high pressure either due to a bolus infusion or asa result of incorrect use of power injectors.[10] In other cases,catheter fracture was not attributed to any cause other thanmere weakening with prolonged use, without any externalsigns of damage, leading to catheter fatigue and thereforea shorter lifespan.[11] In this case, and although a powerinjector was not used, the catheter rupture was concludedto be a cause of high syringe pressure with the use of thestandard 5 cc syringe for flushing when a 10 cc is currentlyrecommended by the manufacturer. It is noteworthy to men-tion that almost all previous cases were reported in the adultoncology population in the setting of contrast or chemothera-peutic agent administration, and upon an extensive literatureresearch, no cases were found in the pediatric population inassociation with a calcium infusion.

Figure 3. Intraoperative ultrasound showing right IJVthrombosis

Figure 4. The catheter post surgical extraction showingdissociation with a small piece of attachment between bothfragments

The discovery of catheter fragmentation in this case wascompletely incidental, upon encountering resistance withthe attempt of a saline flush in the setting of an unblockedcatheter. Other case reports have described a more symp-tomatic clinical presentation that might have roused suspi-cion, most commonly due to direct communication betweenthe embolus and functioning anatomy. The fragment maybe found anywhere along the distal course of the concernedvein; common sites are the superior vena cava, right atrium,right ventricle or even the pulmonary artery. Most of thepatients present with pain at the insertion site followed by anonfunctioning catheter.[12] This was the case in this patient,as she was very irritable prior to the removal of the catheter.However, variability in the presenting clinical picture is doc-umented. One case suffered signs and symptoms indicativeof pneumonia in the setting of a negative chest x-ray onlyto confirm the diagnosis of catheter embolisation through acomputed tomography (CT) scan, where two fragments werefound lodged in the pulmonary artery.[13] Another presen-tation was the onset of palpitations and shortness of breathonce the migrating fragment had eventually arrested withinthe ventricles. On the other hand, some patients only man-ifested mild features such as a simple cough or shoulderpain.[14] In a more uncustomary situation, the patient mayremain entirely asymptomatic for an extended period of time

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that could stretch out for a number of years. One paper hadreported a case that presented with a pulmonary embolismof a fractured catheter that was initially removed 11 yearsago.[15]

Early extraction of the catheter alongside all fractured frag-ments either surgically or through a percutaneous endovas-cular technique is recommended in order to prevent similarsituations to those mentioned above.[12] The latter is gener-ally preferred due to its low adverse event rate and greaterthan 95% success rate.[16] Fortunately in this case, the pa-tient was sent immediately for percutaneous retrieval under

fluoroscopic monitoring before the superimposition of anyfurther complications.

In conclusion, the associated portacath rupture had been at-tributed to the use of incorrect syringe size in relation tothe catheter, which had inadvertently generated high syringepressure. Therefore we recommend verifying the appropriatesize for each syringe specific to the entailing manufacturerbefore its use in order to prevent catheter rupture as a resultof high-pressure syringe.

CONFLICTS OF INTEREST DISCLOSUREThe authors declare they have no conflicts of interest.

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[13] Mahadeva S, Cohen A, Bellamy M. The stuck central venous catheter:Beware of potential hazards. Br J Anaesth. 2002; 89(4): 650-2. PMid:12393372. https://doi.org/10.1093/bja/aef239

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[15] Thanigaraj S, Panneerselvam A, Yanos J. Retrieval of an IV catheterfragment from the pulmonary artery 11 years after embolization.Chest. 2000; 117(4): 1209-11. PMid: 10767267. https://doi.org/10.1378/chest.117.4.1209

[16] Biswas S, McNerney P. Ventricular Tachycardia from a Central LineFracture Fragment Embolus: A Rare Complication of a CommonlyUsed Procedure—A Case Report and Review of the Relevant Lit-erature. Case Reports Crit Care. 2015; 2015: 1-6. Available from:http://www.hindawi.com/journals/cricc/2015/265326/

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